Risk Level 1 Annual Report Questions
GENERAL INFO
A.
B.
Site Owner Information
Owner Name:
Owner Contact:
Owner Address:
E-Mail:
City:
Phone:
State:
Zip:
Site Information
Site Business Name:
Site Contact:
Site WDID No:
E-Mail:
Physical Address:
Phone:
City:
State:
Zip:
FORM 1
C.
STORMWATER POLLUTION PREVENTION PLAN (SWPPP)
C.1.
Has a SWPPP been prepared by a Qualified SWPPP Developer (QSD) for the construction
project?
YES
NO
If NO, Explain: __________________________________________________________________
C.2.
Does the SWPPP include a Construction Site Monitoring Program (CSMP) section/element?
YES
NO
If NO, Explain: __________________________________________________________________
C.3.
Are these documents kept onsite?
YES
NO
If NO, Explain: __________________________________________________________________
D.
GOOD SITE MANAGEMENT “i.e.HOUSEKEEPING”
D.1.
Were good site management “i.e.housekeeping” measures for construction materials
implemented on-site in accordance with CGP and SWPPP?
YES
NO
If NO, Explain: __________________________________________________________________
Based on 2013 Annual Report Questions
Risk Level 1 Annual Report Questions
D.1.a. Was an inventory of the products used and/or expected to be used conducted?
YES
NO
If NO, Explain: __________________________________________________________________
D.2.
Were required good site management “i.e.housekeeping” measures for waste management
implemented on-site in accordance with CGP and SWPPP?
YES
NO
If NO, Explain: __________________________________________________________________
D.2.a. Is there a spill response and implementation element of the SWPPP?
YES
NO
If NO, Explain: __________________________________________________________________
D.3.
Were required good site management “i.e.housekeeping” measures for vehicle storage and
maintenance implemented on-site in accordance with CGP and SWPPP?
YES
NO
If NO, Explain: __________________________________________________________________
D.4.
Were required good site management “i.e.housekeeping” measures for landscape materials
implemented on-site in accordance with CGP and SWPPP?
YES
NO
If NO, Explain: __________________________________________________________________
D.5.
Was a list of potential pollutant sources developed?
YES
NO
If NO, Explain: __________________________________________________________________
D.6.
Were required good site management “i.e.housekeeping” measures to control air deposition of
site materials and from site operations implemented on-site?
YES
NO
If NO, Explain: __________________________________________________________________
E.
NON-STORM WATER MANAGEMENT
E.1.
Were measures to control all non-storm water discharges during construction implemented?
YES
NO
If NO, Explain: __________________________________________________________________
E.2.
Were vehicles washed in such a manner as to prevent non-storm water discharges to surface
waters or to MS4 drainage systems?
YES
NO
N/A
If NO, Explain: __________________________________________________________________
E.3.
Were streets cleaned in such a manner as to prevent unauthorized non-storm water discharges
from reaching surface waters or MS4 drainage systems?
YES
NO
If NO, Explain: __________________________________________________________________
Based on 2013 Annual Report Questions
Risk Level 1 Annual Report Questions
F.
EROSION CONTROLS
F.1.
Were required erosion controls implemented on-site in accordance with CGP and SWPPP?
YES
NO
If NO, Explain: __________________________________________________________________
G.
SEDIMENT CONTROLS
G.1.
Were required sediment controls implemented on-site in accordance with CGP and SWPPP?
YES
NO
If NO, Explain: __________________________________________________________________
G.2.
Were immediate access roads inspected on a daily basis?
YES
NO
If NO, Explain: __________________________________________________________________
G.3.
Was an Active Treatment System implemented on site?
H.
RUN-ON AND RUN-OFF CONTROLS
H.1.
Was all site run-on and run-off effectively managed?
YES
NO
YES
NO
If NO, Explain: __________________________________________________________________
H.2.
Did Risk level 2 dischargers monitor and report run-on from surrounding areas if there was
reason to believe run-on may have contributed to an NAL exceedance?
YES
NO
N/A
If NO, Explain: __________________________________________________________________
I.
Non Applicable for RL 1
J.
INSPECTION, MAINTENANCE AND REPAIR
J.1.
Were all site inspections, maintenance, and repairs performed or supervised by a Qualified
SWPPP Practitioner (QSP)?
YES
NO
If NO, Explain: __________________________________________________________________
J.2.
Were site inspections conducted weekly and at least once each 24-hour period during extended
storm events?
YES
NO
If NO, Explain: __________________________________________________________________
J.3.
Were post rain event inspections conducted?
Based on 2013 Annual Report Questions
YES
NO
Risk Level 1 Annual Report Questions
If NO, Explain: __________________________________________________________________
J.4.
Do your inspection forms/checklists meet the minimum criteria listed in the CGP?
YES
NO
If NO, Explain: __________________________________________________________________
J.5.
During any site inspection was BMP maintenance or repairs required?
YES
NO
If NO, Explain: __________________________________________________________________
J.6.
If BMP maintenance/repair or design change was needed, did implementation begin within 72
hours?
YES
NO
N/A
If NO, Explain: __________________________________________________________________
K.
VISUAL MONITORING
K.1.
Within 2 business days (48 hours) after each qualified rain event, were visual inspections
conducted in compliance with the CGP?
YES
NO
If NO, Explain: __________________________________________________________________
K.2.
Were all storm water discharges that occurred from storage or containment systems visually
observed prior to discharge?
YES
NO
If NO, Explain: __________________________________________________________________
K.3.
Were the time, date, and rain gauge reading recorded for each qualifying rain event?
YES
NO
If NO, Explain: __________________________________________________________________
K.4.
Within 2 business days (48 hours) prior to each predicted rain event, were visual inspections
conducted in compliance with the CGP?
YES
NO
If NO, Explain: __________________________________________________________________
K.5.
Are all visual inspection records retained on-site?
YES
NO
If NO, Explain: __________________________________________________________________
L.
Not Applicable for Risk Level 1
YES
M.
NO
NON-STORM WATER DISCHARGE MONITORING
Based on 2013 Annual Report Questions
N/A
Risk Level 1 Annual Report Questions
M.1.
Were all drainage areas monitored for authorized/unauthorized non-storm water discharges
quarterly?
YES
NO
If NO, Explain: __________________________________________________________________
M.2.
Did visual observations indicate any authorized/unauthorized non-storm water discharges?
YES
NO
If YES, complete Form 2
M.3.
Were effluent samples taken of the authorized/unauthorized non-storm water discharge?
(Analytical data must be entered into the RAW DATA tab in SMARTS)
YES
NO
N/A
If NO, Explain: __________________________________________________________________
M.4.
Were the effluent samples sent to a laboratory certified for such analyses by the State
Department of Health Services?
YES
NO
N/A
If NO, Explain: __________________________________________________________________
M.5.
Were unauthorized non-storm water discharges eliminated?
YES
NO
N/A
If NO, Explain: __________________________________________________________________
N.
NON-VISIBLE POLLUTANT MONITORING
N.1.
Were any breaches, malfunctions, leakages, or spills observed during a visual inspection?
YES
NO
N.2.
How many potential discharges of non-visible pollutants were identified?
___________
N.3.
For each discharge event (of non-visible pollutants), were samples collected in compliance with
the CGP? (Analytical data must be entered into the RAW DATA tab in SMARTS)
YES
NO
N/A
If NO, Explain: __________________________________________________________________
N.4.
For each discharge event was a comparison sample collected (uncontaminated sample that did
not come into contact with the pollutant)? (Analytical data must be entered into the RAW DATA
tab in SMARTS)
YES
NO
N/A
If NO, Explain: __________________________________________________________________
O.
Not applicable to Risk Level 1
P.
RECORDS
P.1.
Are all records of all storm water monitoring information retained on-site?
Based on 2013 Annual Report Questions
YES
NO
Risk Level 1 Annual Report Questions
If NO, Explain: __________________________________________________________________
Q.
Not applicable to Risk Level 1
R.
Not applicable to Risk Level 1
S.
Not applicable to Risk Level 1
T.
TRAINING
T.1.
Was a Qualified SWPPP Practitioner (QSP) in reasonable charge of SWPPP implementation?
YES
NO
If YES, Provide Name: _______________________________________________
and Certificate Number: _____________________________________________
If NO, Explain: __________________________________________________________________
T.2.
Were all individuals conducting BMP installation, inspection, maintenance and repairs trained
appropriately?
YES
NO
If NO, Explain: __________________________________________________________________
T.3.
Are complete training records kept on-site and available upon request?
YES
NO
If NO, Explain: __________________________________________________________________
U.
AUTHORIZED NSWDs DISCHARGED
U.1.
were any authorized NSWDs discharged observed from July-September?
YES
NO
If YES, fill out FORM 2
U.2.
Were any authorized NSWDs discharged observed from October-December?
YES
NO
If YES, fill out FORM 2
U.3.
Were any authorized NSWDs discharged observed from January-March?
YES
NO
If YES, fill out FORM 2
U.4.
Were any authorized NSWDs discharged observed from April-June?
If YES, fill out FORM 2
V.
UNAUTHORIZED NSWDs DISCHARGED
Based on 2013 Annual Report Questions
YES
NO
Risk Level 1 Annual Report Questions
V.1.
Were any unauthorized NSWDs discharged observed from July-September?
YES
NO
If YES, fill out FORM 2
V.2.
Were any unauthorized NSWDs discharged observed from October-December?
YES
NO
If YES, fill out FORM 2
V.3.
Were any unauthorized NSWDs discharged observed from January-March?
YES
If YES, fill out FORM 2
V.4.
Were any unauthorized NSWDs discharged observed from April-June?
YES
If YES, fill out FORM 2
Based on 2013 Annual Report Questions
NO
NO
Risk Level 1 Annual Report Questions
FORM 2
DATE/TIME OF
OBSERVATION
AUTHORIZED OR
UNAUTHORIZED
(CHECK ONE)
___/___/___
Authorized
____:____
AM PM
Unauthorized
___/___/___
Authorized
____:____
AM PM
Unauthorized
___/___/___
Authorized
____:____
AM PM
Unauthorized
___/___/___
Authorized
____:____
AM PM
Unauthorized
___/___/___
Authorized
____:____
AM PM
Unauthorized
Based on 2013 Annual Report Questions
SOURCE AND
LOCATION
OF NSWD
NAME OF
NSWD
DESCRIBE NSWD CHARACTERISTICS
Indicate whether NSWD is clear,
cloudy, or discolored, causing staining,
contains floating objects or oil sheen,
has odors, etc.
At the NSWD
At the NSWD
Source
Drainage Area and
Discharge Location
DESCRIBE ANY REVISED OR NEW
BMPs AND PROVIDE THEIR
IMPLEMENTATION DATE
Risk Level 1 Annual Report Questions
FORM 3
Enter a general summary of any BMP deficiencies identified for each quarter and the corrective actions taken. Maximum up to 1000 characters.
July-Sept
Quarter
Oct-Dec
Quarter
Jan-March
Quarter
April-June
Quarter
Based on 2013 Annual Report Questions
Risk Level 1 Annual Report Questions
Certification of Annual Report
“I certify under penalty of law that this document and all attachments were prepared under my
direction or supervision in accordance with a system designed to ensure that qualified
personnel properly gather and evaluate the information submitted. Based on my inquiry of the
person or persons who manage the system, or those persons directly responsible for gathering
the information, the information submitted is to the best of my knowledge and belief, true,
accurate, and complete. I am aware that there are significant penalties for submitting false
information including the possibility of fine and imprisonment for knowing violations.”
I and/or personnel acting under my direction and supervision, have reviewed the responses to
these Annual Report questions and find that it meets the requirements of the State Water
Resources Control Board (SWRCB), National Pollution Discharge Elimination System
(NPDES) General Permit for Stormwater Discharges Associated with Construction Activities.
Signature of QSP
_____________________________
Signature of Construction/Project Manager
Based on 2013 Annual Report Questions
_____________________________